Registered Nurses' Association of Ontario (RNAO) best practice guideline on the assessment and management of vascular access devices

The impact of enhancing vascular access care quality through monitoring and training: A multicentre observational study

AIM

This study evaluates the impact of monitoring a primary quality indicator and the effect of training on improving the care and maintenance of vascular access devices.

DESIGN

A prospective, quasi-experimental, multicentre study with 10 periodical cross-sections from 2017 and 2020.

PARTICIPANTS

Adult patients hospitalised over 24 h, with or without vascular access device, excluding those in emergency, psychiatry, outpatients or minor surgery units.

METHODS

The study included 10 cross-sections between 2017 and 2020 in all participating hospitals, using the INCATIV® (Quality Indicators in Intravenous Therapy and Vascular Access) questionnaire. Training sessions for nursing staff were conducted between cross-sections, involving face-to-face sessions in open classrooms and clinical sessions in the units, based on the study Care bundle.

RESULTS

53,991 vascular accesses were analysed, with an average INCATIV Index score of 8.95 (SD: 1.32), showing improvement from 8.09 in the first cross-section to 9.21 in the last. Significant variability was observed between hospitals, with secondary hospitals scoring lower on the INCATIV® Index. Training interventions 1 and 2 showed significant improvement across all hospital categories, whereas intervention 5 did not show significant effects. Compliance with main recommendations was studied, with a notable decrease in phlebitis rates from 4.45% in the first cross-section to 1.23% in the tenth.

CONCLUSION

The study developed a single indicator to assess and quantify vascular access care quality. It demonstrated that implementing a care bundle through serial training interventions and continuous assessment by nursing staff, supported by process indicators and data availability on the study platform, significantly reduces complications and enhances the quality and safety of vascular access care.

Which is the safer option for adult patients between peripherally inserted central catheters and midline catheters: a meta-analysis

BACKGROUND

Peripherally inserted central catheters (PICC) and midline catheters (MC) are widely used for intravenous infusions in oncology and critically ill patients. However, controversy remains regarding which method is superior. This meta-analysis systematically compares the safety differences between these 2 methods of intravenous catheterization.

METHODS

Eligible studies comparing PICC and MC were identified through searches in 6 databases. Thrombosis is the primary endpoint, while secondary endpoints include other complications, cost, and satisfaction rate.

RESULTS

Fourteen studies with 20,675 patients were analyzed. Based on patient data, the MC group exhibited higher rates of catheter-related superficial vein thrombosis (SVT) (risk ratio [RR]: 0.42 [0.28, 0.64]), infiltrations (RR: 0.27 [0.12, 0.62]), and leaks (RR: 0.16 [0.05, 0.53]). In contrast, the PICC group had more catheter-related bloodstream infections (RR: 1.95 [1.15, 3.32]). Considering catheter days, the MC group showed increased total complications (RR: 0.51 [0.26, 0.99]), catheter-related thrombosis (deep vein thrombosis [DVT]+SVT) (RR: 0.41 [0.18, 0.95]), and leaks (RR: 0.17 [0.05, 0.64]). In the PICC group, the top 3 complications were catheter occlusions (20 per 1,000 catheter days [CDs]), pain (15 per 1,000 CDs), and phlebitis (11 per 1,000 CDs); for the MC group, they were leaks (33 per 1,000 CDs), premature removals (22 per 1,000 CDs), and catheter-related DVT (22 per 1,000 CDs). Additionally, the PICC group had higher dissatisfaction rates (RR: 4.77 [2.33, 9.77]) and increased costs.

CONCLUSIONS

Compared to MC, PICC appears to be a safer intravenous catheterization option for adult patients, exhibiting fewer complications. However, the higher associated costs and lower satisfaction rates of PICC warrant serious attention.

Complication Rates of Peripherally Inserted Central Catheters in Oncologic Versus Non-Oncologic Patients

OBJECTIVES

Peripherally inserted central catheters are commonly used in cancer patients and provide vascular access for the administration of chemotherapy, antibiotics, or parenteral nutrition. Besides many advantages, they represent a source of possible complications such as catheter related blood stream infection, catheter occlusion, or thrombosis. In this study, the catheter-related complication rate between oncologic and non-oncologic patients was compared.

METHODS

This retrospective cohort-study included 411 patients who underwent their first catheter placement at the Vienna General Hospital-Medical University of Vienna from January 2013 to June 2018. Patient demographics and catheter-related parameters were collected and statistically analyzed using a competing risk model.

RESULTS

Mean catheter dwell time was 27.75 days. The overall complication rate was 7.54% (2.72 per 1000 catheter days). Underlying malignant disease (hazard ratio: 0.351, 95% confidence interval [CI]: 0.133-0.929, P = .035) and chemotherapy administration (hazard ratio: 2.837, 95% CI: 1.088-7.394, P = .033) were significantly associated with the occurrence of any kind of complication. Catheter related blood stream infection was observed among 11 (2.68%) patients and again significantly associated with chemotherapy administration (hazard ratio: 4.545, 95% CI: 1.178-17.539; P = .028). Thrombosis was found in 7 (1.70%) patients and occlusion in 13 (3.16%) cases.

CONCLUSIONS AND IMPLICATIONS FOR NURSING PRACTICE

Choice of venous access is an interdisciplinary decision with emphasis on patient participation. In oncologic patients, our data suggests that the benefits of peripherally inserted central catheters regarding costs, invasiveness, and accessibility might be outweighed by the higher rate of complications associated with the device. This becomes even more important in a community care setting, where standardized handling procedures and patient education play a pivotal role in device safety.

Results of a long-term, prospective study on complications of central venous catheter in pediatric patients with hematologic-oncologic diseases

BACKGROUND

Central venous catheter (CVC)-related complications remain a significant cause of morbidity in pediatric hematology-oncology. We prospectively surveyed the incidence of CVC-related complications in children with hematologic-oncologic diseases.

PROCEDURE

Five-hundred-eighty-one CVCs were inserted in 421 patients from January 2010 to June 2022 (153,731 CVC days observation; follow-up data up to December 31, 2022).

RESULTS

Overall, 671 complications were recorded (4.365/1000 CVC days): 49.7% malfunctions (1.88/1000 CVC days, 4.8% of CVC early removals), 23.9% bacteremia (0.90/1000, 15.1%), 19.6% mechanical complications (0.74/1000, 70.2%), 20.1% localized infections (0.76/1000, 17.1%), 0.5% thrombosis (0.02/1000, 33.3%). At multivariate analysis, risk factors for malfunction were Broviac-Hickman type of CVC (hazard ratio [HR] 2.5) or Port-a-cath (HR 3.4) or Proline (HR 4.3), p < .0001; for bacteremia double-lumen CVC (HR 3.2, p < .0001); for mechanical complications age at CVC insertion under median (HR 4.5, p < .0001) and Broviac-Hickman (HR 1.6) or Proline (HR 2.7), p = .01; finally for localized infections Broviac-Hickman (HR 2.9) or Proline (HR 4.4), p = .0001. The 2-year cumulative incidence of premature removal was 23.5%, and risk factors were age at CVC insertion under median (HR 2.4, p < .0001), Broviac-Hickman (HR 2.3) or Proline (HR 4.2), p < .0001.

CONCLUSIONS

Premature removal occurs in approximately 20%-25% of long-term CVCs. A surveillance program has a fundamental role in identifying the risk factors for CVC complications and the areas of intervention to improve CVC management.

An Explanatory Model of Vascular Access Care Quality: Results of a Cross-Sectional Observational Study

The management of nursing care regarding patients' vascular access is a priority. This study determines the contribution of the variables involved in the quality of care and maintenance of vascular access (VA) devices in admitted patients in the Valencian Community.

METHODS

Using the STROBE statement, an observational, cross-sectional study was conducted on 1576 VA devices. Data were collected using the INCATIV Questionnaire. We performed a multivariate analysis of the questionnaire variables.

RESULTS

In total, 50% had a good or very good assessment of the VA condition. This was positively correlated with anatomical location, dressing type, dressing date record, use of needle-free connectors (NFCs), date of last dressing change, presence of phlebitis, visibility of the insertion site and characteristics of the dressing's condition (p < 0.001). The model indicated that the presence of phlebitis was the clearest predictor of a poor VA care assessment (OR = 20.579), followed by no visibility of the insertion site (OR = 14.209). Results also indicated that uncovered VA lumens or no NFCs used were related to a negative quality assessment.

CONCLUSION

By managing and controlling these variables, the likelihood of providing optimal care is ensured. This enables the establishment of a standardised care approach for all nursing professionals and the building of a new quality indicator.